Complications of carotid endarterectomy
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
The accepted indications for carotid endarterectomy (CEA) balance the long-term benefit of stroke reduction with the risk of perioperative complications, requiring overall morbidity and mortality rates associated with CEA to be low, otherwise the intervention cannot be justified. Complications following CEA can be related to underlying cardiovascular disease or other comorbid conditions, or to the technique of performing carotid endarterectomy.
Postoperative complications of CEA, including myocardial infarction, perioperative stroke, postoperative bleeding, and the potential consequences of cervical hematoma, nerve injury, infection, and carotid restenosis, which may require repeat carotid intervention, are reviewed here. The indications for carotid intervention are reviewed separately. (See "Management of asymptomatic carotid atherosclerotic disease" and "Management of symptomatic carotid atherosclerotic disease" and "Carotid endarterectomy".)
The accepted indications for carotid endarterectomy (CEA) balance the long-term benefit of stroke reduction with the risk of perioperative complications, requiring that overall morbidity and mortality rates associated with CEA should be low (<6 percent in symptomatic patients; <3 percent in asymptomatic patients) to justify the intervention [1,2]. The morbidity and mortality rates used by the American Heart Association (AHA) to formulate recommendations for CEA are more than 10 years old and based upon data that are even older. Two large randomized trials likely more accurately reflect the contemporary risk of stroke or death following CEA:
●The European trial (International Carotid Stenting Study [ICSS]) randomly assigned patients to receive carotid endarterectomy or carotid stenting for treatment of symptomatic carotid stenosis . The 120 day all-cause mortality for the 857 symptomatic patients in the endarterectomy group was 0.8 percent. The 120-day combined any stroke or procedural death rate was 4.2 percent.
●In North America, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported combined results for symptomatic and asymptomatic patients . In 1240 patients assigned to endarterectomy (47.3 percent asymptomatic), the 30-day death rate was 0.3 percent, and the rate of any periprocedural (30-day) stroke or death or postprocedural ipsilateral stroke was 2.3 percent.
- Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995; 91:566.
- Biller J, Feinberg WM, Castaldo JE, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1998; 97:501.
- International Carotid Stenting Study investigators, Ederle J, Dobson J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375:985.
- Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363:11.
- Wu TY, Anderson NE, Barber PA. Neurological complications of carotid revascularisation. J Neurol Neurosurg Psychiatry 2012; 83:543.
- Hill MD, Brooks W, Mackey A, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation 2012; 126:3054.
- Saedon M, Singer DR, Pang R, et al. Registry report on kinetics of rescue antiplatelet treatment to abolish cerebral microemboli after carotid endarterectomy. Stroke 2013; 44:230.
- Heyer EJ, Mergeche JL, Bruce SS, et al. Statins reduce neurologic injury in asymptomatic carotid endarterectomy patients. Stroke 2013; 44:1150.
- Faggioli G, Pini R, Mauro R, et al. Perioperative outcome of carotid endarterectomy according to type and timing of neurologic symptoms and computed tomography findings. Ann Vasc Surg 2013; 27:874.
- Sfyroeras GS, Bessias N, Moulakakis KG, et al. New cerebral ischemic lesions after carotid endarterectomy. Ann Vasc Surg 2013; 27:883.
- Barbetta I, Carmo M, Mercandalli G, et al. Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits. J Vasc Surg 2014; 59:440.
- Goldberg JB, Goodney PP, Kumbhani SR, et al. Brain injury after carotid revascularization: outcomes, mechanisms, and opportunities for improvement. Ann Vasc Surg 2011; 25:270.
- Chamorro A, Vila N, Saiz A, et al. Early anticoagulation after large cerebral embolic infarction: a safety study. Neurology 1995; 45:861.
- Anzuini A, Briguori C, Roubin GS, et al. Emergency stenting to treat neurological complications occurring after carotid endarterectomy. J Am Coll Cardiol 2001; 37:2074.
- National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581.
- Liu ZJ, Fu WG, Guo ZY, et al. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg 2012; 26:576.
- Liu Z, Shi Z, Wang Y, et al. Carotid artery stenting versus carotid endarterectomy: systematic review and meta-analysis. World J Surg 2009; 33:586.
- Blackshear JL, Cutlip DE, Roubin GS, et al. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation 2011; 123:2571.
- Boulanger M, Camelière L, Felgueiras R, et al. Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting: Systematic Review and Meta-Analysis. Stroke 2015; 46:2843.
- Youkey JR, Clagett GP, Jaffin JH, et al. Focal motor seizures complicating carotid endarterectomy. Arch Surg 1984; 119:1080.
- Reigel MM, Hollier LH, Sundt TM Jr, et al. Cerebral hyperperfusion syndrome: a cause of neurologic dysfunction after carotid endarterectomy. J Vasc Surg 1987; 5:628.
- Naylor AR, Ruckley CV. The post-carotid endarterectomy hyperperfusion syndrome. Eur J Vasc Endovasc Surg 1995; 9:365.
- Coutts SB, Hill MD, Hu WY. Hyperperfusion syndrome: toward a stricter definition. Neurosurgery 2003; 53:1053.
- Kablak-Ziembicka A, Przewlocki T, Pieniazek P, et al. Predictors of cerebral reperfusion injury after carotid stenting: the role of transcranial color-coded Doppler ultrasonography. J Endovasc Ther 2010; 17:556.
- Bouri S, Thapar A, Shalhoub J, et al. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg 2011; 41:229.
- Pennekamp CW, Tromp SC, Ackerstaff RG, et al. Prediction of cerebral hyperperfusion after carotid endarterectomy with transcranial Doppler. Eur J Vasc Endovasc Surg 2012; 43:371.
- Clagett, GP, Robertson, JT. Surgical considerations in symptomatic disease. In: Stroke: Pathophysiology, diagnosis and management, Barnett, HJM, Mohr, JP, Stein, BM, Yatsu, FM (Eds), Churchill Livingstone, New York 1998. p.1209.
- Hosoda K, Kawaguchi T, Ishii K, et al. Prediction of hyperperfusion after carotid endarterectomy by brain SPECT analysis with semiquantitative statistical mapping method. Stroke 2003; 34:1187.
- Powers AD, Smith RR. Hyperperfusion syndrome after carotid endarterectomy: a transcranial Doppler evaluation. Neurosurgery 1990; 26:56.
- Dalman JE, Beenakkers IC, Moll FL, et al. Transcranial Doppler monitoring during carotid endarterectomy helps to identify patients at risk of postoperative hyperperfusion. Eur J Vasc Endovasc Surg 1999; 18:222.
- Fujimoto S, Toyoda K, Inoue T, et al. Diagnostic impact of transcranial color-coded real-time sonography with echo contrast agents for hyperperfusion syndrome after carotid endarterectomy. Stroke 2004; 35:1852.
- Piepgras DG, Morgan MK, Sundt TM Jr, et al. Intracerebral hemorrhage after carotid endarterectomy. J Neurosurg 1988; 68:532.
- Sundt TM Jr, Sharbrough FW, Piepgras DG, et al. Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 1981; 56:533.
- Kidwell CS, Saver JL, Mattiello J, et al. Diffusion-perfusion MRI characterization of post-recanalization hyperperfusion in humans. Neurology 2001; 57:2015.
- Karapanayiotides T, Meuli R, Devuyst G, et al. Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke 2005; 36:21.
- Kieburtz K, Ricotta JJ, Moxley RT 3rd. Seizures following carotid endarterectomy. Arch Neurol 1990; 47:568.
- Doig D, Turner EL, Dobson J, et al. Incidence, impact, and predictors of cranial nerve palsy and haematoma following carotid endarterectomy in the international carotid stenting study. Eur J Vasc Endovasc Surg 2014; 48:498.
- Payne DA, Twigg MW, Hayes PD, Naylor AR. Antiplatelet agents and risk factors for bleeding postcarotid endarterectomy. Ann Vasc Surg 2010; 24:900.
- Comerota AJ, Difiore R, Tzilinis A, Chahwan S. Cervical hematoma following carotid endarterectomy is morbid and preventable: a 12-year case-controlled review. Vasc Endovascular Surg 2012; 46:610.
- Rosenbaum A, Rizvi AZ, Alden PB, et al. Outcomes related to antiplatelet or anticoagulation use in patients undergoing carotid endarterectomy. Ann Vasc Surg 2011; 25:25.
- Morales Gisbert SM, Sala Almonacil VA, Zaragozá García JM, et al. Predictors of cervical bleeding after carotid endarterectomy. Ann Vasc Surg 2014; 28:366.
- Stone DH, Nolan BW, Schanzer A, et al. Protamine reduces bleeding complications associated with carotid endarterectomy without increasing the risk of stroke. J Vasc Surg 2010; 51:559.
- Fokkema M, de Borst GJ, Nolan BW, et al. Clinical relevance of cranial nerve injury following carotid endarterectomy. Eur J Vasc Endovasc Surg 2014; 47:2.
- Cunningham EJ, Bond R, Mayberg MR, et al. Risk of persistent cranial nerve injury after carotid endarterectomy. J Neurosurg 2004; 101:445.
- Wang TK, Bhamidipaty V, MacCormick M. First bite syndrome following ipsilateral carotid endarterectomy. Vasc Endovascular Surg 2013; 47:148.
- Mann CD, McCarthy M, Nasim A, et al. Management and outcome of prosthetic patch infection after carotid endarterectomy: a single-centre series and systematic review of the literature. Eur J Vasc Endovasc Surg 2012; 44:20.
- Stone PA, Srivastava M, Campbell JE, et al. A 10-year experience of infection following carotid endarterectomy with patch angioplasty. J Vasc Surg 2011; 53:1473.
- Zierler RE, Bandyk DF, Thiele BL, Strandness DE Jr. Carotid artery stenosis following endarterectomy. Arch Surg 1982; 117:1408.
- Counsell CE, Salinas R, Naylor R, Warlow CP. A systematic review of the randomised trials of carotid patch angioplasty in carotid endarterectomy. Eur J Vasc Endovasc Surg 1997; 13:345.
- LaMuraglia GM, Stoner MC, Brewster DC, et al. Determinants of carotid endarterectomy anatomic durability: effects of serum lipids and lipid-lowering drugs. J Vasc Surg 2005; 41:762.
- Goodney PP, Nolan BW, Eldrup-Jorgensen J, et al. Restenosis after carotid endarterectomy in a multicenter regional registry. J Vasc Surg 2010; 52:897.
- Dorigo W, Pulli R, Fargion A, et al. Comparison of open and endovascular treatments of post-carotid endarterectomy restenosis. Eur J Vasc Endovasc Surg 2013; 45:437.
- Lal BK, Beach KW, Roubin GS, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol 2012; 11:755.
- Hertzer NR, Bena JF. Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy. J Vasc Surg 2013; 58:926.
- Kang J, Conrad MF, Patel VI, et al. Clinical and anatomic outcomes after carotid endarterectomy. J Vasc Surg 2014; 59:944.
- Pavela J, Ahanchi S, Steerman SN, et al. Grayscale median analysis of primary stenosis and restenosis after carotid endarterectomy. J Vasc Surg 2014; 59:978.
- Chan RC, Chan YC, Cheung GC, Cheng SW. Predictors of restenosis after carotid endarterectomy: 17-year experience in a tertiary referral vascular center. Vasc Endovascular Surg 2014; 48:201.
- Sadideen H, Taylor PR, Padayachee TS. Restenosis after carotid endarterectomy. Int J Clin Pract 2006; 60:1625.
- Fokkema M, de Borst GJ, Nolan BW, et al. Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy. J Vasc Surg 2014; 59:8.
- Ladowski JS, Shinabery LM, Peterson D, et al. Factors contributing to recurrent carotid disease following carotid endarterectomy. Am J Surg 1997; 174:118.
- Hellings WE, Moll FL, De Vries JP, et al. Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy. JAMA 2008; 299:547.
- Pauletto P, Puato M, Faggin E, et al. Specific cellular features of atheroma associated with development of neointima after carotid endarterectomy: the carotid atherosclerosis and restenosis study. Circulation 2000; 102:771.
- Bond R, Rerkasem K, Naylor AR, et al. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg 2004; 40:1126.
- Bekelis K, Moses Z, Missios S, et al. Indications for treatment of recurrent carotid stenosis. Br J Surg 2013; 100:440.
- Coscas R, Rhissassi B, Gruet-Coquet N, et al. Open surgery remains a valid option for the treatment of recurrent carotid stenosis. J Vasc Surg 2010; 51:1124.
- Tu J, Wang S, Huo Z, et al. Repeated carotid endarterectomy versus carotid artery stenting for patients with carotid restenosis after carotid endarterectomy: Systematic review and meta-analysis. Surgery 2015; 157:1166.
- Fokkema M, Vrijenhoek JE, Den Ruijter HM, et al. Stenting versus endarterectomy for restenosis following prior ipsilateral carotid endarterectomy: an individual patient data meta-analysis. Ann Surg 2015; 261:598.
- Mansour MA, Kang SS, Baker WH, et al. Carotid endarterectomy for recurrent stenosis. J Vasc Surg 1997; 25:877.
- Kresowik TF, Bratzler DW, Kresowik RA, et al. Multistate improvement in process and outcomes of carotid endarterectomy. J Vasc Surg 2004; 39:372.
- Stoner MC, Cambria RP, Brewster DC, et al. Safety and efficacy of reoperative carotid endarterectomy: a 14-year experience. J Vasc Surg 2005; 41:942.
- GENERAL CONSIDERATIONS
- PERIOPERATIVE STROKE
- Evaluation and treatment
- MYOCARDIAL INFARCTION
- HYPERPERFUSION SYNDROME
- CERVICAL HEMATOMA
- NERVE INJURY
- Frequency and distribution
- Specific nerves
- - Hypoglossal nerve
- - Facial nerve/mandibular nerve
- - Vagus /laryngeal nerves
- - Glossopharyngeal nerve
- - Sympathetic nerves
- Surgical site/patch infection
- CAROTID RESTENOSIS
- Risk factors
- Indications for reintervention
- CEA versus CAS for recurrent stenosis
- SUMMARY AND RECOMMENDATIONS